BTCanada would like your help.We want to hear from mothers, regardless of
how or when you had your child(ren), about bias in obstetrics and how it
impacted your decisions and your life after childbirth.What things were you told were true only to
find out that they weren’t for you? Please drop us a letter or an email.Please specifically state that your comments
are about bias in obstetrics.We will
not reply to your comments unless you specifically request that.

The medical definition of bias is
‘any trend in the collection, analysis, interpretation, publication or review
of data that can lead to conclusions that are systemically different from the
truth.’

Bias is also defined as ‘an attitude
that inhibits impartial judgment or an unfair policy stemming from prejudice. It is an error caused by systemically
favouring some outcomes over others.’

There are no shortages of bias in obstetrics, both now and in the past.When we’ve had a chance to hear your voices
we will publish an article highlighting them on this page.

BIAS IN OBSTETRICS

Penny Christensen, Chair, Birth Trauma Canada

Bias induced myopia and naiveté is used as an excuse to disregard women’s
rights.“But we didn’t know” becomes
their mantra when they are caught in their lies.And for some this is true.There really are people so stupid they can’t
figure out they are stupid and there is no cure for ignorance in this
case.They are hapless victims of their
conditioning and training. Most bias
can’t trace this as its only source.Most ‘stupidity’ is inexcusable.Claiming ignorance is hollow and indefensible.Most people guilty of perpetuating
obstetrical myths and bias aren’t naïve and they have the intellectual capacity
for reasoned thought.They just don’t use it.They have the ability to see cause and
effect.They have first hand knowledge
of it and they have had for decades, even centuries.Some recognize this and are too afraid to
speak up lest they be ridiculed or ostracized for speaking the truth.When those brave few do speak they are
treated like lone voices in the wilderness but change doesn’t happen without
them.

An excellent essay on the slow pace of rational transformational change can be found here.

The most disheartening reason for perpetuating bias and myth in any form of
systemic discrimination is also the most common.They simply choose not to change their ways
because their station in life is threatened if they do.They hold tight to their attitudes.When chinks start to appear in their armour
they just beat their drums louder and with more viciousness.It is why bias is so hard to overcome. They
refuse to ask questions they don’t want to hear the answers to.They conduct studies that ignore variables
that discredit their hypotheses.They
pontificate endlessly without considering or caring about their victims’
experience. It doesn’t occur to them to
even ask.In the face of credible
evidence they shut their eyes tight, cover their ears and hum.They blather on about supporting evidence-based
science and empowering women but many of them do neither.It is childish and unprofessional behaviour
and it strips them of their credibility. Humans can always be counted on to preserve their own groundless sense of
superiority over others.People will
elevate their own status by sacrificing the rights of others.And this doesn’t take very long.Put a group of equals in a room, assign one
group to be the ‘controllers’ and the other group to be the ‘controlled’ and
watch the degradation start to happen within hours.Overall, we aren’t a very altruistic or
superior species.That doesn’t stop me
from being optimistic about our evolution as a species.I’ve just learned to temper my optimism with
a heavy dose of realism.Bias, and the discrimination it spawns, makes chumps out of educated
people.This is why education is only a
partial remedy.People need to know how
to recognize bias, refuse to believe it and then resolve to banish it.Bias exists without any credible evidence and
often without a shred of common sense.This isn’t the same as a lack of information supporting it.There is usually no shortage of supporting
blah, blah, blah, but, of course, not all information is valuable.Bias hurts people, often badly and
permanently.Sometimes it kills
them.It robs people of their
credibility and it blocks progress and advancement.It is the reason our descendents will wonder
of us “How could they be so moronic.The
truth was so obvious.Why couldn’t they
see it?”It is the reason we ask the
same of our ancestors.What is true for some isn’t necessarily true for others.A world without bias recognizes that.Universal human rights give people the right
to make their own decisions.They do not
give other people the right to make decisions for them.Give women access to unbiased, intelligent
information and let them make their own decisions.Don’t assume they are not capable of that
because they, most assuredly, are.

Consider
these statements:

1)Cancer patients do not have the right to safe and effective pain control
because pain is a natural consequence of cancer and cancer is a naturally
occurring human condition.2)Those in burn units who are directly responsible for their injuries have
no right to effective pain relief or compassion.If they don’t like that choice they shouldn’t
have burned themselves.3)Encourage surgical patients to forego pain relief both during and post
surgery.Instead, have a staff member providing
one-on-one encouragement not to have effective pain relief.Patients should be encouraged to think of
their suffering as ‘a good pain’, to ‘work with the pain’ and to embrace ‘an
altered sense of consciousness’.Infer
that anyone who wants pain relief is a weak minded failure.Encourage competitive suffering with post
surgery get-togethers.4)Hospital policy should ensure that all palliative care patients ask at
least twice before their request for pain relief is considered.If death is imminent consider denying the
request.5)Trauma sustained during torture results in damaged bodies and damaged
psyches.Depositing a large sum of money
in their bank account will make them forget all about it.6)Psychiatric studies show that pre-rape courses reduce the terror women
feel during and after rape.In a civilized society these statements
would beggar belief, and with good cause.They are offensive, insensitive and cruel.

Now
consider the same statements when they are made about pregnant women:

1)Maternity patients do not have the right to safe and effective pain
control because pain is a natural consequence of childbirth and childbirth is a
naturally occurring womanly condition.2)Those women who get pregnant should not expect choice in delivery
options, nor should they expect pain relief or compassion.If they don’t like that they shouldn’t get
themselves pregnant.3)Encourage obstetrical patients to forego pain relief during and after
childbirth.Instead, have a staff member
providing one-on-one encouragement not to have effective pain relief.Patients should be encouraged to think of
their suffering as ‘a good pain’, ‘to work with the pain’ and ‘to embrace an
altered state of consciousness’. Infer
that anyone who expects effective pain relief is a weak-minded failure.Encourage
competitive suffering with post birth get-togethers.4)Hospital policy should ensure that all obstetrical patients ask at least
twice before their request for pain relief is considered.If birth is imminent consider denying the
request.5)Trauma sustained during childbirth results in damaged bodies and damaged
psyches.As soon as you put her baby in
her arms she will forget all about it.6)Psychiatric studies show that pre-natal courses reduce the terror women
feel during and after childbirth.These statements should beggar belief but
they actually reflect obstetrical attitudes for the past several decades and,
in many obstetrical circles (this country included), they are still widely accepted.Such attitudes maintain a deplorable status
quo.They prevent advancement.Systemic discrimination always involves the
attitude that a certain sub-group of the population is not deserving of humane
treatment.They are considered
inferior.What is considered
unacceptable for other humans is considered acceptable for the group
discriminated against.This is true for
any form of systemic discrimination, whether it is based on race, ethnicity
and, in this case, gender.Underlying
all obstetrical bias is misogyny.Only recently have some obstetrical
associations around the world back-tracked from their long held views that
childbirth is the only situation where patients can be denied pain relief,
under the care of a physician, when safe and effective methods of pain control
are available.

A)Childbirth is healthy

Childbirth is NOT healthy.It isn’t now and it never has been.I’m not sure if people who say this are being
wilfully deceptive or just plain stupid.The end result is the same. Women
are not well served by this bias.Women
told this preposterous statement by people who know better, or should know
better, have unrealistically high expectations about motherhood and the
childbirth experience.When fertility rates go up so does the rate
of women’s health problems.Parity is
directly related to urinary incontinence, anal incontinence,
uterine/vaginal/rectal/urinary prolapse, sexual pain and/or lack of sensation
during intercourse, chronic pelvic pain and neurological problems throughout
the body.Parity is also associated with
heart disease, diabetes, gallstones, thyroid disorders, Alzheimer’s disease and
a number of different cancers (breast cancer, renal cancer, etc.)Having children for women is also associated
with obesity – and all that entails.Women who have children have much higher unemployment rates and this
puts them at higher risk for living in poverty.And don’t even get me started on the effects of stress.None of this stuff is healthy.Ignoring or dismissing the obvious
maintains the status quo and affords no hope for positive change that will
improve women’s short term and long term health.

B)Childbirth is natural (and therefore good)

Nature
isn’t just about fuzzy puppies and rainbows.Nature is also cruel, unfair and tragic.None of the people who espouse this obstetrical bias that I have met, to
date, are willing to live in caves and forego the technological advancements
that enhance their lives. Humankind
exists solely because we can use our brains and ingenuity to counteract nature
and none of us would last very long in nature.We can’t run very fast, we can’t see or hear very well, we have no body
covering to protect us from heat, cold, insects and the sun’s radiation.We are susceptible to all kinds of infectious
and non-infectious disease.The human
body is not a superior design.We need
our brains, ingenuity and technology to survive.

Over 500,000 women die directly of childbirth every year.Most are in the developing world because they do not have access to life
saving medical technology and qualified obstetrical care.Many, many more suffer life altering
morbidity problems.In the developed
world we have less maternal mortality and far more ‘near misses’.My point is that just because something is
natural doesn’t mean it is safe.For those who feel that if it is natural it
must be good, consider all the things that are natural and definitely not good
for you:Tornadoes, earthquakes, tsunamis,
mudslides, floods, hungry polar bears, any other predatory animal, spiders the
size of dinner plates (Really. In Australia. Ewww), poisonous
spiders, poison ivy, poison oak, any other poisonous plant, those big snakes
than can crush you, HIV, tuberculosis, those ticks that carry Lime Disease,
mice that carry Hantavirus, any other infectious disease, marauding elephants,
cyanide, arsenic, radon, hurricanes, death, botulism toxin. You get my point.

C)A healthy woman’s body knows how to give
birth

Does a healthy man’s body ‘know’ not to
have prostate problems?Does a healthy
child’s body ‘know’ not to get cancer?To
suggest they do is both ludicrous and cruel.Bad things happen to people everyday precisely because their bodies
don’t ‘know’.As addressed above, the
human body isn’t an anatomical wonder.Men have urethras that pass through the prostate gland – a gland that
gets bigger as they age, restricts urine flow and has a strong tendency to
become malignant.Some children are born
with a pre-disposition to cancer and other sad genetic afflictions.It is not their fault.It is not a woman’s fault either when things
turn bad during childbirth.We are the
only species where birth involves pushing an infant that is too large through a
space that is too small. There is no
better way to make someone feel like a failure than to pump up unrealistic
expectations about what their bodies are capable of.The role of medicine and technology is to
address these inadequacies and to make us healthy and keep us healthy despite
anatomical deficiencies.Cemeteries prior to modern medicine are
full of healthy young women and their babies whose bodies didn’t ‘know’ and who
didn’t make it.These tragedies still
happen today but no where near the same numbers.Today they are ‘near misses’.None of these women are failures.Those who don’t make it are tragic
victims.Those who had near misses are
survivors.

D)
Childbirth is only painful if a woman thinks it will be painful.

Good grief.Childbirth is painful for the same reason kidney stones are painful or
surgery without anesthesia is painful. Pain stimuli activates neurotransmitters
responsible for pain.They transmit that
information to the brain and the brain responds.Fear is an adaptive response to pain.Without this association we would never learn
who or what to trust and what dangerous things we should avoid.Telling someone to relax while they are
suffering immensely is maladaptive and counter-intuitive.It is another way to make women feel like
failures.Why this bias developed with
respect to women and childbirth speaks more about disregard for women than
rational thought.

E)Non-pharmaceutical methods are effective pain
relief

There are two effective ways to relieve
pain.Both are pharmaceutical.The first is to prevent pain messages from
reaching the brain (like a spinal and/or epidural) and the second is to mess
with how the brain receives pain messages (like opium derivatives).The second way has serious drawbacks.Doses large enough to provide complete pain
relief for the mother would kill the baby, and likely kill the mother.Any dose alters the mother’s perception of
reality.Breathing techniques, water baths,
massages, having someone in your face with ‘encouragement’ and going to your
happy place do not relieve pain.They
layer other sensations on top of pain or give you something else to think about
while you are suffering.If these
techniques actually relieved pain anesthesiologists would be all over them in
other areas of the hospital.You would
read headlines like:

“Man
passes kidney stones painlessly over three days, without morphine, relying
solely on his Kidney Stone Passing support person and breathing techniques.”

“Anesthesiologists
are shocked by pain-free open heart surgery performed without anesthesia in the
Jacuzzi.Patient sipped herbal tea and
chatted with the surgical team during surgery.”

F)Childbirth is painful because women need to
be punished for being women.

This is un-adulterated misogyny and still
widely accepted.

G)Women need to suffer to be good mothers

Same comment as above.If this were true we wouldn’t hear from good
mothers who didn’t suffer and from good mothers who did suffer whose babies
serve as a trigger for traumatic stress symptoms and who struggle with the
tremendous guilt that brings.

H)Women need to reach an ‘altered state of
consciousness’ to properly give birth.

This ‘altered state of consciousness’ is
dissociation and dissociative amnesia.It is a human response to severe psychological and physical stress and
it should be avoided, not encouraged.

I)
It is a woman’s fault if she has a miscarriage or her baby has a birth
defect.She must have done something
wrong.

15% of pregnancies end in miscarriage.2-3% of babies born will have a birth
defect.They are not caused by eating
pineapple, having a glass of wine with supper, watching acrobats, bathing, full
moons or any of the other preposterous and blaming theories out there.Heaping this kind of guilt on women who are
struggling with pregnancy loss or struggling with the burden of coping with congenital
defects in their children is indefensible.

Developmental biology is a complex
science.There are numerous chances for errors
during fetal development.A woman cannot
control her genetics or those of her fetus.

J)A healthy baby is enough to make up for the
trauma of childbirth

A prize, no matter how wonderful, does not
cure physical or psychological trauma in any situation.Offensive statements like this isolate and
further traumatize all trauma victims.Monetary compensation does not end PTSD for torture survivors.You don’t tell someone who has lost his legs
that he should be happy he didn’t lose his arms.It is no different for women after
childbirth.The experience of childbirth
and the baby are two separate things. The attitude that a healthy baby makes women forget the trauma of their childbirth experience is patently untrue. Women carry that experience with them for life. Fatalism and stoicism are not the same as getting over it.

K)“ Cesarean surgery on demand will
have disastrous social and financial consequences for health internationally”

Blaming women who choose cesarean section
for destroying the social and financial fabric is vicious. Heck, let’s blame them for conflict in the Middle East and pine beetle deforestation as well.It would make as much sense.Those with specific biases often use words
like ‘empowerment of women’ and rail against ‘views not supported by evidence’,
when they, as in this case, are guilty of the same transgressions.Scare mongering and manipulation are not
empowering to anyone other than those wielding power.Denigrating those who don’t agree with your
point of view is not respectful, to women or anyone else.

When I was first made aware of the source
of this statement I was speechless.It
is a direct quote from the Canadian Midwives Association found in their rant
against maternal request cesarean section.I was not expecting such a visceral, inflammatory attack on a woman’s reproductive
choice and autonomy from an association of women who fight so hard for a
woman’s right to choose a less managed childbirth experience. We can’t blame patriarchal misogyny for
this.This is blatant woman on woman
abuse.

I want to make it clear that not all
midwives think this way.I’ve talked to
some who find this stance as repugnant as I do.

I strongly support a woman’s right to choose.Midwives have been maligned and controlled
for centuries and I can’t blame them for feeling a bit scrappy.They provide a professional service strongly desired
by some women who have every right to make that choice and that choice should
be fully funded but a midwife-attended vaginal birth is not the only acceptable
choice women can make. The choice any woman makes is the right one for her and
should be respected, not denigrated.

L)Episiotomies are necessary to protect the
pelvic floor.

This bias was once widely held.Millions of women around the world were
subjected to routine episiotomies for decades in the belief that cutting the
perineum would have a better outcome for the pelvic floor than spontaneous lacerations.Studies supporting this bias appeared in
medical journals and doctors and nurses everywhere believed this.There was lots of information to support this
stance but not a shred of credible evidence.That is the nature of bias.Deliberately damaging the pelvic floor to save the pelvic floor is as
inexcusably stupid in hindsight as it should have been during the decades women
were subjected to routine episiotomies.

M)If it is in a medical journal, it must be
true. (Or how to recognize a spin doctor)

This simply isn’t true.Many medical journals (particularly with
respect to childbirth) are propaganda vehicles for a particular bias.One estimate states that only 0.1% of all
medical studies published every year can claim to be both scientifically sound
and potentially relevant to doctors and patients.There are many days when I think that
estimate is overly generous.Dr. Richard
Smith’s The Trouble with Medical Journals [RSM Press, 2006] provides
insight about this serious problem.Integrity in medicine remains as elusive (and worth fighting for) as
integrity in any other business. There are people working hard to support
genuine evidence-based obstetrical information, more humane treatment of
pregnant women and factual accountability and transparency.More power to them.It has been, and continues to be, an uphill
struggle.

How can you distinguish the bad from the
good?It is a problem even those with an
understanding of the scientific process struggle with.One of the first ways to educate oneself
about the prevalence of obstetrical bias is to read archived obstetrical
journals.With the benefit of hindsight
the bias (and related misogyny) presented in many of these published studies
practically jumps off the page.How do
you recognize bias without the benefit of hindsight?I’ll take one study and dissect it to show
what tools of deception are used.You
can look for the same in other studies.

I’ve chosen ‘Maternal mortality and severe morbidity associated with low-risk
planned cesarean delivery versus planned vaginal delivery at term’.It is authored and championed by the
Public Health Agency of Canada; the Department of Obstetrics and Gynaecology,
University of British Columbia, Vancouver; Perinatal Epidemiology Research
Unit; Department of Obstetrics and Gynaecology and of Pediatrics, Dalhousie
University; the Faculty of Nursing and Department of Obstetrics, Gynecology and
Reproductive Sciences, University of Manitoba; Departments of Pediatrics and of
Community Health Sciences, University of Calgary; and the Departments of
Pediatrics and of Epidemiology and Biostatistics, McGill University,
Montreal.The lead author is Shiliang
Liu.It was published in the Canadian
Medical Association Journal (CMAJ) Febraury 13, 2007.Supposedly illustrious connections, to be
sure.Their conclusions were that planned cesarean
deliveries (PCD) had higher morbidity rates than those associated with planned
vaginal deliveries (PVD) when comparing healthy pregnant women at term.This was a surprising conclusion to
me. Given their own admission that approximately 16-17% of the 'planned cesareans' they included involved a trial of labour should have been the first red flag to them as well before making such pronouncements. I have read many medical studies
comparing PCD with PVD that arrive at the opposite conclusion – both in North America and around the world.The National Institute of Health (United States),
in a statement about maternal request cesarean section, concluded that the
quality of evidence available wasn’t good enough to say which was safer for the
mother – an uncomplicated PVD or an uncomplicated PCD.How then, can different research scientists
arrive at such diverse conclusions?Rule #1 in recognizing bias in medical studies
is:Are there other better designed studies
around the world that dispute the study in questions’ conclusions?Could there be?Is there controversy about the conclusions or
results?

Rule
#2 :Look for study design flaws.

The U.K. instituted thromboprophylactic
guidelines for cesarean deliveries in 1995.Cesarean deaths (and morbidity) associated with thrombosis and
thromboembolism declined sharply thereafter.(The Society of Obstetricians and Gynaecologists of Canada – SOGC –
wouldn’t follow suit for another 5 years.)Other guidelines for better care of cesarean mothers were accepted and
more widespread around the same time. [spontaneous vs. manual extraction of
placenta, non-closure vs. closure of peritoneal layers, more reliance on
regional vs. general anesthesia, etc.] Any
study seriously comparing mortality and morbidity rates associated with PVD and
PCD would ensure advancements were accounted for in your study period.This study purposely looked at 14 years of
Canadian (except Quebec and Manitoba) restrospective data – from 1991 to
2005 - with the majority of planned cesareans prior
to 2000.This is a perfect example
of how study design can be used to mask bias and skew results.

Rule
#3:Look for what they aren’t telling
you as much as you look at what they are.

There is no better way to ‘prove’ your
point of view than to ignore variables that don’t support your position.Let’s look at the stuff they aren’t telling
us.

Maternal Mortality:This study concluded that ‘the difference we
observed in in-hospital maternal deaths between women undergoing planned
cesarean vs. planned vaginal delivery was
not significant.’(The emphasis is
mine)In reality no women died in the
planned cesarean group whereas 41 (0.02%) died in the planned vaginal delivery
group.Are these deaths
insignificant?I wonder if they would
have considered these numbers insignificant if a similar percentage of deaths
occurred in the PCD group and not in the PVD group?

How was maternal morbidity defined?

*Hemorrhage
requiring hysterectomy (0.03% PCD; 0.1% PVD)

Hemorrhagerequiring transfusion (0.7% PVD; 0.2% PCD)

Any
hysterectomy (PCD 0.6%; PVD 0.2%) (not sure if this
includes those women who had finished childbearing and required a hysterectomy
for other medical reasons.It is
certainly easier to do this at the same time as a cesarean.Requiring a hysterectomy after a vaginal
delivery for the same reasons wouldn’t be captured in this data set as it would
require a separate operation.None of
this is mentioned.)

* Consider how these variables could change
if the study period included only data after 2001 with the changes in
obstetrical practice I’ve previously mentioned.This study also looked at planned cesarean deliveries for breech
deliveries as representative of all planned elective cesareans but breech
cesareans are more difficult than cesareans for cephalic presentations and
would reasonably be expected to carry higher maternal risks.

How did each individual mother feel about
their experiences?What about the
benefits of avoiding anxiety and pain of labour and delivery?Sedation, tranquilizers, anti-depressants and
anti-anxiety pharmaceutical use is part of pregnancy and especially labour and
delivery.How about a reduction in
concern about the baby’s health?It is also worth mentioning that this study
ignored the very real problem of doctor and hospital variations.Including statistics from rogue doctors and
substandard hospitals misrepresents the ideal.The way morbidity was defined in this study would favour higher adverse
effects for surgical deliveries than for vaginal deliveries given this reality.

Rule
#4Was the study independent?

Often medical studies are designed or paid for
by pharmaceutical companies, medical device companies or people who would like
to keep their jobs.There are a number
of dirty tricks used to hide negative results in such cases.I don’t think that factored into this study
but it is something you should be aware of when you look for bias in other
studies.Many reputable medical journals insist on
independent statistical analysis of raw data as a means of reducing bias and
maintaining integrity.This study did
not have independent statistical analysis.Censorship by publishers and editorial
staff is another area that limits the integrity of some journals.Unless these controversies are exposed by
someone with integrity and inside information or are picked up by a responsible
member of the media these issues never see the light of day, yet they have a
profound impact on what appears in medical journals.

As an example, consider the Canadian Medical Association Journal (CMAJ)
and its recent struggle with editorial independence.

On February 20, 2006, Dr. John Hoey and Dr.
Anne Marie Todkill, long-standing senior editors of CMAJ, were fired by the
publishers – the Canadian Medical Association (CMA).The CMA had recently decided that their long
standing policy of making women come to them for post-coital contraception
[levonorgestral or Plan B] violated a woman’s right to reproductive choice
because of the barriers they had placed in a woman’s way.They made Plan B available without
prescription.The CMAJ sent 13 women to
buy the emergency contraceptive over-the-counter in pharmacies across Canada, and
report their experiences.The
pharmacists asked them for personal data, including the woman’s name, address,
date of last menstrual period, when she had unprotected sex, customary method
of birth control, and the reason for dispensing the medication.This was done at the recommendation of the
Canadian Pharmacists Association (CPA), which also advised members to store the
information permanently on their computers.Clearly the CPA had their anti-choice barriers in place.The Canadian Women’s Health Network (bless
their hearts) said the obvious by stating that collecting this information was
unnecessary and a violation of privacy.The CPA complained to the CMA, demanding that the names of the
pharmacists be removed from the CMAJ article (bullies never like being exposed)
and the CMA ordered the CMAJ to comply.The CMA then fired Hoey and Todkill, stating they wanted to ‘freshen up’
the journal.The rest of the full time
editorial staff resigned on February 28, 2006.The former editorial staff at the CMAJ
launched a new open-access journal [Open Medicine] in April, 2007.The CMAJ went on to admit the episode
raised serious concerns about the integrity of the journal and its
reputation.Duh. I give them credit for
laying the cards on the table and admitting mistakes.Positive change doesn’t happen without an
initial admission of guilt. A warning posted on the CMAJ website by the
editorial committee states “In our view, any attempt by the CMA to impose its
influence on the editors would be catastrophic for the CMAJ’s reputation as
well as damaging to the reputation of the CMA.”Too little, too late?Such bad behaviour by the CMA and CPA isn’t
restricted to Canada.Censorship and medical integrity issues are
serious problems being addressed (hopefully) around the world.This cautionary tale highlights the problem
of medical solidarity at all costs and it influences what you will see, and
just as importantly, what you won’t see in medical journals.

N) “A labouring woman needs first to be
protected against any stimulation of the thinking part of her brain - the
neocortex. This part of the brain needs to take a back seat and allow the
primal ‘unthinking' part of the brain connected to basic vital functions to
take over. A woman needs to be in a world where she doesn't need to think or
talk.

This chauvinistic endorsement of trauma induced dissociation is widely
quoted by several (but not all) who champion ‘natural’ childbirth.Statements like this are from that past era
where women were encouraged ‘not to worry their pretty heads’.Being in a world where you are actively
encouraged not to think or talk sounds like a setting for some B grade horror
movie.Not thinking is a bizarre strategy
to champion for thinking, feeling humans.I haven’t met a woman yet who wasn’t an intelligent, thinking, feeling
type.My advice to any woman
contemplating pregnancy is to put that thinking neocortex into overdrive, not
shelve it.You NEED to think and gather
as much information as you can to make an informed decision that is right for
you.It is vital that you think. Thinking is not a bothersome affliction. It is not something you should turn off, or
accept having turned off, through pain and humiliation induced dissociation or
mind altering drugs.

o) "Epidurals will hurt your baby"

There is no more creepy or insidious (and highly effective) way to
manipulate women than to use their maternal love and concern for their child as
a weapon against them.You can force
women to accept all manner of horrors if they feel they are doing it for their
baby.That is exactly what this bias
is.Mother love should be respected as
the beautiful thing it is and not used as an excuse to hurt mothers.There is no credible evidence to support this
bias.There has never been any credible
evidence to support this bias.There
will never be any credible evidence to support this bias because it is not
true.

P) “No pain, No gain”

Unless you view labour and delivery as an
extreme sport – and some do – there is nothing about this bias that serves
women well.Denying effective pain
relief to woman during labour, delivery and the post partum without a
scientifically valid reason – and there really isn’t any - is misogyny.Despite this it is still a widely held bias.

Q)

“Vaginal births are safer than planned cesareans”

“Planned cesareans take longer to recover from than spontaneous
vaginal deliveries”

If either of these were
true we wouldn’t hear so many stories where the opposite was true.If either of these were true many
obstetricians, anesthesiologists, nurses and others with access to inside
information wouldn’t choose a planned cesarean for their own deliveries or
those of their loved ones.If this were
true the vast majority of horror stories we hear about wouldn’t be about
planned vaginal deliveries.And if this
was true most of the medical malpractice suits filed against obstetricians,
midwives and hospitals wouldn’t be about planned vaginal deliveries.

R) “Evolution/Nature wouldn’t make
childbirth dangerous.”

People with this bias have a poor understanding of evolution.They assume that the end product of evolution
is better than the starting point and that maladaptive traits are eliminated as
generations go on.I’m not saying that
natural selection isn’t a powerful and effective force.It certainly is and it isn’t a very pretty
process.Human technology shields us
from the full effects of natural selection.Left to the unchecked processes of natural selection (like getting rid
of modern shelter/medicine/optometry/dentistry, etc. ) most of the human
population, regardless of gender or age, on earth right now would die, including
those with a poor understanding of evolution.I wouldn’t last very long myself.Letting natural selection run amok is the last thing a civilized human society
would, or should, allow.But even if we
did evolution would not eliminate all maladaptive traits.It wouldn’t even eliminate all the stuff that
doesn’t contribute anything.Our own
human genome is ample evidence of that.Most of the DNA in each of us is evolutionary baggage.It doesn’t code for anything yet we replicate
the whole shebang every time a cell divides.

Mutation is a spontaneous process that can occur during cell division/DNA
replication.This can happen during egg
or sperm division (meiosis) or during human growth and maintenance that occurs
constantly in people of all ages (mitosis).Cell division is a fascinating, elegant and complex process that is
prone to errors, as all complex processes are.Most mutations are bad or neutral.Very few give an individual an advantage.All the positive attitudes about evolution
and nature in the world will not stop this.

Chance – blind, dumb luck or the lack thereof – also influences
evolution.It doesn’t matter if you are
the strongest, healthiest person around - if you are covered in a mudslide,
drowned in a flash flood, swept up in a tornado, killed in a car accident,
whatever, and you haven’t reproduced you obviously aren’t going to be
evolutionarily successful.

Consider how many maladaptive traits are carried through from one generation
to the next, even though those with the disease generally don’t reproduce.Cystic fibrosis, hemophilia, muscular
dystrophy, colour blindness are but four examples.There are plenty more.Consider our evolutionary vestiges.We have a tail bone but humans don’t have
tails.They would look darned stupid and
they would make finding a pair of jeans that fit right even more difficult and
we don’t need them.Our early
evolutionary ancestors did and it gave them a survival advantage.Evolution hasn’t rid us of this or any other
trait we no longer use.A trait will
continue in any species as long as enough people have that trait AND it doesn’t
kill more individuals than can survive with it.Put another way, evolution allows certain traits to continue because
they don’t reduce fitness enough.As well,
many maladaptive traits aren’t even seen until after reproduction occurs.

Evolution is measured in the number of reproducing offspring – not lifespan
or quality of life.Evolution doesn’t
give a whit about whether the individual likes it.Consider the lives of two women.The first was a happy camper who was very
rarely sick.She died at 100, not
because she had anything terribly wrong with her.She was sharp as a whip and still
active.She was hit by a bus because her
recent limited mobility didn’t allow her to move out of the way in time.She never had children.Another woman dies at 62 of complications
from diabetes.She also had moderate
dementia.Life had been hard for her, as
one would expect.She had two children
who both had children. It is this woman
who was evolutionarily successful, not the first.It is her genes passed to the next
generation.

Evolution will not eliminate any
trait that is required for survival in another capacity.Evolution will never act to reduce the size
of the human head because without our increased capacity for intelligence we
couldn’t survive.Evolution will never
act to increase the size of the human pelvis because to do so would negate, or
seriously limit, our bipedal mobility which would clearly not be advantageous
to survival.Bipedalism requires the
legs to be close enough together so the person can walk and this limits the
size of the pelvic opening.

This would be a good time to also consider
cultural pressures on evolution.Two
women walk into a bar.The first is
stunningly beautiful.She is tall and
slim with large breasts and a beautiful face.The other is tall, with moderate sized breasts, a little plump, a
beautiful face but her hips are huge.She has a tough time getting on the bar stool.Both are wearing the same outfit.Which one do all the men in the bar want to
go home with?

For those interested in learning more about human birth and evolution there
is a book called Human Birth: An
Evolutionary Perspective [Wendy R. Trevathan, Aldine Publishers, 1987] that
can give more insight.

S) “Millions of women have given birth
vaginally, so you can too.”

Those with this bias never complete that thought process and see the bigger
picture.Certainly millions of women
have given birth vaginally and survived.And millions of them haven’t and many, many more have survived but with
negative consequences.

T) “I had a vaginal birth without drugs/
planned cesarean/ vaginal birth with drugs/ suffered terribly/ etc. and you
should too.”

People with this bias have what I like to call Centre of the Universe
Syndrome (CUS).The afflicted suffer
from the delusion that, as the centre of the universe, everyone must do and
think exactly as they do and think.Of
course, this affliction isn’t concentrated in obstetrics and it certainly
doesn’t affect only women.Recently, at
an office, I witnessed two men fighting over the best way to put a cutting
board into the dishwasher.Both insisted
their way was the best way and the fists were ready to fly.A wise and diplomatic co-worker suggested
that, at each of their houses, they could put the cutting board in their
dishwashers the way they wanted but maybe it would be best today to wash it in
the sink.Three perfectly acceptable
ways to get the job done.

Everyone has their own opinions and beliefs.They are the product of their own experiences.A person’s fears are a valid part of who they
are.What works for someone doesn’t make
it suitable for someone else.We are the
centre of our own universe but we are not the centre of anyone else’s.

U) “A baby is worth the terrible
suffering”

I wonder if people who have this bias think that babies that didn’t result
in terrible suffering and maternal injuries aren’t worth it?

V) “Countries
with some of the lowest perinatal mortality rates in the world have cesarean
rates of less than 10%.There is no
justification for any region to have a rate higher than 10-15%”.

These two sentences are the only basis for
the oft quoted rationalization for reducing cesarean rates to this level.It is from the World Health Organization
(WHO) in a one page letter to The Lancet in the August, 1985 issue.What one
sentence has to do with the other is a mystery to me.It is worth remembering that the continued
and shamefully high maternal death rate around the world – particularly in
developing countries and in spite of WHO rhetoric – is not because of planned
cesareans.They occur during and after
planned vaginal deliveries.

Cesarean rates have no bearing on increased
mortality rates.Sierra Leone has the
highest maternal mortality rate in the world (at 2000/100,000 live births) and
an extremely low cesarean rate and I would definitely recommend keeping Sierra
Leone off your radar if you are looking for places to book a planned
cesarean.Iceland has the lowest maternal
mortality rate in the world (at 0/100,000 live births).Iceland’s cesarean rate is around
20%.

There are a number of reasons attributed to
high maternal mortality rates.The
number one reason is poor quality of care and that is true whether you are
talking about vaginal or cesarean birth. A whopping 40% of all maternal deaths in the US are
attributed to this and are entirely preventable.That they are not is shameful. The vast
majority of maternal deaths around the world occur for three major reasons –
post partum hemorrhage, infection and obstructed labour.Post partum hemorrhaging is actually less of
a risk with planned cesarean and is not a high risk factor for mortality in any
country with the ability, or the political will, to offer blood transfusions to
women.Infection is not a killer if
asceptic technique (and that isn’t rocket science) and antibiotics are
available.Obstructed labour is not a
killer if access to humane, qualified and competent obstetric surgery
(cesarean) is available.

In developed countries maternal mortality
is also linked to things like more mothers living with chronic and serious
disease (like diabetes) and rising obesity rates.Maternal mortality rates also appear to increase
when there is a change to better reporting methods, a recent change in the US.

W) Women can’t be misogynists.

Yes, they can.History is littered
with female misogynists walking in lock step with their male counterparts.Every step forward in respecting human rights
for women throughout history has been a long battle and much of the worst
resistance has come from other women.This isn’t a flaw seen only in women.Rosa Parks was subjected to abuse and calls to back down and mind her
place by other black people –women and men- when she famously refused to sit at
the back of the bus.The SS assigned
other willing Jewish people – men and women - to subjugate those sent to
concentration camps.It happens among
oppressed people as a means to survive both physically and psychologically.

Let me introduce you to Louise Silverton.Her attitude toward women proves we haven’t exorcized that reality
today.I reproduce her words below.She made these comments in 2008.Louise Silverton is the secretary-general of
the Royal College of Midwives (UK).(or the Head Matron at “The Let’s Keep
Things Medieval School
of Midwifery”.I can never keep those two entities
straight.)

“An increasing number of women under
40 are less prepared to undergo the physical trauma of childbirth than their
predecessors.Women under 40 were more
likely to have an 'epidural in a way that their predecessors wouldn't'.”

“Labour is 'unbelievably painful’”

“Women should be charged a fee for an
epidural in an attempt to reduce women’s access to pain relief.”

'Society's tolerance of pain and
illness has reduced significantly.Women
are less tolerant of labour pains because they haven't developed tolerance of
pain. For example, if they get period pain they will either take Nurofen or go
to their GP.

'Women are trying to remove the
symptoms of pregnancy as much as they can. They are seeking to control everything.
Choosing to have a caesarean gives you an element of control.'

“I want Britain's rate brought closer to
the 15 per cent recommended by the World Health Organisation.Caesareans have been normalised in the minds
not just of women but also midwives and obstetricians.”

“The celebrity culture of having a baby and
two weeks later being seen in a slinky dress, having lost weight, is affecting
women’s views of caesareans.”

“Caesareans have become too easy to
obtain”

Her battle against modernity only serves to make her irrelevant in the
modern world.And this is a modern
world.Those ‘under 40s’ she refers to
are the first generation of women to most fully reap the benefits of an
emancipation process that began over a century ago.They are the first generation of girls raised
in the Western world to believe they are not second-class citizens and they
take that basic right for granted, as well they should.They are not second-class citizens.We have, thankfully, not remained stuck in a
world that banned women and girls from career options, higher education, the
right to own property, the right to vote and participate in political
processes, the right to drive a vehicle, the right to wear pants, the right to
contraception, the right not to marry, the right to have a bank account, the
right to pick our own partners and the right to be considered people.It is well past the time women were
considered first-class, valuable citizens in obstetrics as well.

There are several questions I’d like to ask Louise Silverton.Why do you need to control women?Why does it bother you to see women trying to
control their childbirth experience?Why
do you need to see them suffer?Why a
fee for epidurals?Do you hate poor
women more than you hate rich women?Or
are poor women just easier to control?Why does it bother you so much that women are ‘wearing slinky dresses,
having lost weight, two weeks after a cesarean’?If midwives were allowed to do cesareans and
epidurals would your attitude change?Why do you think your version of ‘normal’
should be everyone’s version of normal?Any
other ways you want to toughen up girls besides shaming them for going to their
doctor or taking pain killers for period pain?

As a young school girl (mid 1970’s, rural Canada) girls and women weren’t
allowed to wear pants.One September a
new principal (a man) changed all that.I remember looking out the school window with all the other youngsters
as five middle age and older women emerged from the car they were chauffeured
in. (Women couldn’t drive then
either).They marched up the sidewalk,
each one trying to look more virtuous than the other, intent on setting this
man straight and protect the next generation of girls from…well I’m not sure
from what.He did not back down. Several letters were written to the municipal
paper disparaging him and his decision as well as disparaging girls and women
for wearing pants – and gasp – driving a car. They were called sluts and whores and loose
women.He still did not back down but some
of the girls brave enough initially were forced by the hatred leveled at them
to wear dresses and accept rides.Because of his courage and the courage of some women in that community girls
in that backward little town have had the right to wear pants and drive ever
since.So what happened to those five
furious women?One went to her grave about
10 years later refusing to wear pants or drive a car.Today the other four are too embarrassed by
their behaviour to talk about it.All of
them drive and wear pants.

Midwife Silverton (and her ilk) should take a relaxing drive in her car and
buy a new pair of pants while considering all the reasons she could be
wrong.Considering how history will
judge her isn’t a bad idea, either.

Mickey
Meece reports in the New York Times [May 9, 2009] that “ It’s probably no surprise that most bullies are men, as a survey by the
Workplace Bullying Institute, an advocacy group, makes clear.But a good 40 per cent of bullies are
women.And at least the male bullies
take an egalitarian approach, mowing down men and women pretty much in equal
measure.The women appear to prefer their
own kind, choosing other women as targets more than 70 per cent of the time.”

The role some men play in undermining human
rights for women is well documented.It
is a far more difficult conversation, from a feminist perspective, to
acknowledge the unpleasant reality that it is often women who are their own
worst enemies.Those mean girls from
high school don’t go away when they become adults.

I, like many women, have preferred to
ignore this reality for too long, despite being reminded on a near daily basis,
that much of the abuses of women in obstetrics are done by other women.Knowledge is the best defence and we can’t
continue to stick our heads in the sand about this, as I have.Phyllis
Chesler, thankfully, doesn’t have my limitations.She has written a thoughtful, intelligent
book from a feminist perspective entitled Women’s
Inhumanity to Women [Lawrence Hill Books, 2009], that has helped me more
fully understand why some women behave this way.

X) “Women
are masochists”

“The
traits that compose the core of the female personality are feminine narcissism,
masochism and passivity.”

“The
current generation of entitled young women come to labour unprepared for the
experience and expecting it to be easy, or expecting the work to be ‘done for
them’.”

Anonymous
Canadian obstetrician, 2008

The first quote was taken from the gold
standard of obstetrical textbooks in the 1970s.The wording of that nasty bit of misogyny was softened in later editions
and removed completely by the 1990s.Unfortunately, removing words doesn’t eliminate the attitude.The second quote about ‘entitled’ young women
who have no right to a humane childbirth experience is just as chilling.We have a medical specialty where a
significant percentage of practitioners believe that 1) women are masochists
and 2) they aren’t entitled to be treated as anything else.Does it get any creepier?I don’t think so.

The human spectrum is pretty diverse.Undoubtedly there are some women (and men)
who derive pleasure from their own suffering.If that is what floats their boat, so be it.But all women aren’t masochists.Aren’t now, haven’t been in the past and
won’t be in the future.

Y) "Only stupid women have kids"

I would be a rich woman if I was paid every time I heard these words or variations of them. In response I present the Motherhood Initiative for Research and Community Involvement (MIRCI), formerly the Association for Research on Mothering (ARM) and these words.

(Both books sold through the Association
for Research on Mothering (ARM) - now Motherhood Initiative for Research and Community Involvement - www.motherhoodinitiative.org). You can also purchase these books (and many more stellar and thought provoking titles) through

The Association for Research on Mothering (ARM)
- now
Motherhood
Initiative for Research and Community Involvement -
offers wonderful scholarly analysis and mother-wisdom narratives based on the
editors’ own original work and the work of wise women before them and around
them.They look at the entrenched – and
damaging – societal mother bashing that serves to enforce the perception of
maternal inadequacy.“In other words,
“experts” serve to inform children that mothers aren’t smart or capable enough
to know how to raise their children without being told”.Andrea O’Reilly argues for empowered
mothering that celebrates women’s agency – rejecting ‘sacrificial mothering’
for a mothering model that “recognizes that both mothers and children benefit
when the mother lives her life and practices mothering from a position of agency,
authority, authenticity, and autonomy” (italics are mine as I think this is
such a true and powerful statement).

How many times have I heard the obstetrical
bias that ‘only stupid women have kids’ or that “women aren’t bright enough to
assess their own risks and make their own decisions”?It is an offensive myth and MIRCI blows it out of the water.Quoting Sara Ruddick in Maternal Thinking (an
essay in Joyce Trebilcot’s 1984 collection titled Mothering: Essays in
Feminist Theory) “The work of mother’s demands that mothers think; out of
this need for thoughtfulness, a distinctive discipline emerges”.